February 22, 2017

PPACA Repeal Threatens Prevention and Public Health Fund for Rural Health

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The Patient Protection and Affordable Care Act (PPACA) established the Prevention and Public Health Fund (PPHF), and by law, the Fund must be used to provide for expanded and sustained national investment in preventative public health programs to improve health, enhance healthcare quality, and help restrain the rate of growth in private and public healthcare costs.

First authorized in 2010, to date the Fund has invested in a broad range of evidence-based activities from the federal to state to local community levels, including clinical and community prevention activities such as chronic disease management initiatives, research, public health infrastructure operations, initiatives to address college suicides, smoking and tobacco prevention, surveillance and tracking, programs for low-income mothers, and public health workforce training.

Many who work on the front lines implementing these initiatives and who are making a difference are rightfully worried that a PPACA repeal could eliminate the Fund at a crucial point in time, when it is needed to reduce the estimated $3.2 trillion annually spent to treat diseases and illnesses with medical programs, drugs, and services. Also in the equation is the fact that Republicans are in position to repeal the PPACA without any support from Democrats, and while big issues loom – loss of insurance exchanges, potentially impacting 20 million, and Medicaid expansion being at risk –  no one is mentioning some of the other provisions embedded within the PPACA that are at risk of being repealed. It is this very law where the heart of public health is located.

Without including nearly $1 billion in other appropriations, the public health system could nearly collapse. It is so critical that the premise of funding prevention, the core of population health, is that it not lonely saves lives, but saves money. This is demonstrated through the following: only about 3 percent of our healthcare spending is focused on prevention and public health, when 75 percent of our healthcare costs are actually related to preventable conditions. Additionally, every 10-percent increase in funding for public health programs within the scope of community-based focus is estimated to actually reduce deaths attributable to preventable causes by 1 to 7 percent – and a $2.9 billion investment in disease prevention programs implemented at the community-based level was estimated to save $16.5 billion annually within five years. To round out the impact of public health funding, take into consideration the Feb. 4 Centers for Disease Control and Prevention (CDC) report regarding studies and statistics tracking the top five preventable deaths that are widening the gap of health in rural and minority population versus urban and majority, and one can only imagine the despair that could be created without such funding. 

Money Flow

While the PPACA authorized $18.75 billion for the Fund between the 2010 and 2022 fiscal years, and another $2 billion after that, the actual funding for the Fund began at $500 million back in in 2010 and was meant to actually rise to $2 billion per year by 2015.  This measure was seen as a mandate to actually protect the funding from ever being reduced or removed from the “annual appropriations process.”

Tracking the Fund even more specifically, back in December 2014, then-President Obama signed the Consolidated and Further Continuing Appropriations Act of 2015 into law, allocating $1 billion for preventative care in the Fund for the 2015 fiscal year. Of that, $885 million was allocated to the CDC for several critical areas of public health – diabetes, heart disease, prevention of healthcare infections, and epidemics and tobacco control. The remainder of the $1 billion was dispersed to the Substance Abuse and Mental Health Services Administration as well as the Administration for Community Living’s Administration on Aging. Also in the mix came sequestration, cutting another $73 million, reducing the Fund to $927 million. 

But Wait: There’s More

Also not widely known is the fact that the PPACA not only created the Prevention and Public Health Fund as the nation’s first mandatory funding for public health, it also created the National Prevention Strategy, a sweeping development program that for the first time actually focuses on social determinants of health and individual behavioral choices. Areas of work include long-term conservation solutions, transforming neighborhoods of opportunity, data collection, and studies of communities of populations.

Public health isn’t without National Quality Strategy Implementation: this tri-aim of strategy focuses on affordable care, better healthcare, and the establishment of “Healthy People, Healthy Communities,” which critically focuses on improving the health of the U.S. population with proven interventions to address environmental, social, and behavioral determinants of health. There are also six priorities within the National Quality Strategy to support the promotion of quality healthcare, and two of them have a focus to improve public health: a) working with communities to promote widespread use of best practices to enable healthy living; and c) promoting the most effective prevention and treatment practices for the leading causes of mortality.

Massive Support

A total of about $626 million has been dispersed across the nation to initiatives meant to impact the public health wellness of communities within each respective state. Additionally, the Preventive Health and Health Services (PHHS) block grant provides grant dollars to all 50 states, Washington, D.C., eight U.S. territories, and two American Indian tribal nations, all totaling $160 million each year that is entirely funded by the PPHF fund.

Devastating Impact of Loss

Although the aforementioned programs are just a fraction of all the programs, services, and research funding by the PPHF, all told, states would lose more than $3 billion over the next five years from grants and programs supported by the fund (per the Trust for America’s Health analysis). Millions could be affected and lose service via cuts in funding for programs such as Alzheimer’s prevention, chronic disease self-management, fall prevention, heart disease and stroke prevention, and more.

In Closing

Prevention is the foundation of public health. In an era of value-based reimbursement, technology, quality, and outcomes, it will be difficult to achieve health improvements while lowering costs without the Prevention and Public Health Fund. This could be an epidemic, causing a greater disparity for rural, minority, and underserved programs. Additionally, even more focus and work will be encumbered in every facet of the healthcare and associations as a result.

While the United States has the potential to be one of the healthiest populations in the world, we spend too much and have very little in outcomes to show for it: we rank 27th out of 36 industrialized nations in terms of life expectancy. With this in mind, we can’t afford to lower or eliminate public health funding. Without the PPHF, states will lose more than $3 billion over the next five years for grants and programs supported by the Fund.

If health is our first wealth, without the Prevention and Public Health Fund, we could be prevention/population health-penniless.

Janelle Ali-Dinar, PhD

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president. She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx and is a member of the RACmonitor editorial board.  

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